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Aims Freedom from atrial fibrillation (AF) at 1 year can be achieved in 50–70% of patients undergoing catheter ablation. Recurrent AF early after ablation most commonly terminates spontaneously without further interventional treatment but is associated with later recurrent AF. The aim of this investigation is to identify clinical and procedural factors associated with recurrence of AF early after ablation. Methods and results We retrospectively analysed data for recurrence of AF within the first 3 months after catheter ablation from the randomized controlled AXAFA–AFNET 5 trial, which demonstrated that continuous anticoagulation with apixaban is as safe and as effective compared to vitamin K antagonists in 678 patients undergoing first AF ablation. The primary outcome of first recurrent AF within 90 days was observed in 163 (28%) patients, in which 78 (48%) patients experienced an event within the first 14 days post-ablation. After multivariable adjustment, a history of stroke/transient ischaemic attack [hazard ratio (HR) 1.54, 95% confidence interval (CI) 0.93–2.6; P = 0.11], coronary artery disease (HR 1.85, 95% CI 1.20–2.86; P = 0.005), cardioversion during ablation (HR 1.78, 95% CI 1.26–2.49; P = 0.001), and an age:sex interaction for older women (HR 1.01, 95% CI 1.00–1.01; P = 0.04) were associated with recurrent AF. The P-wave duration at follow-up was significantly longer for patients with AF recurrence (129 ± 31 ms vs. 122 ± 22 ms in patients without AF, P = 0.03). Conclusion Half of all early AF recurrences within the first 3 months post-ablation occurred within the first 14 days post-ablation. Vascular disease and cardioversion during the procedure are strong predictors of recurrent AF. P-wave duration at follow-up was longer in patients with recurrent AF. Trial registration Clinicaltrials.gov identifier NCT02227550

Objective: Atrial fibrillation (AF) rhythm gives rise to an irregular response in ventricular activity, preventing the use of standard ECG-derived risk markers based on ventricular repolarization heterogeneity under this particular condition. In this study, we proposed new indices to quantify repolarization variations in AF patients, assessing their stratification performance in a chronic heart failure population with AF. Methods: We developed a method based on a selective bin averaging technique. Consecutive beats preceded by a similar $RR$ interval were selected, from which the average variation within the ST-T complex for each $RR$ range was computed. We proposed two sets of indices: 1) the 2-beat index of ventricular repolarization variation, ( ${\mathrm{I}_{\rm{V2}}}$ ), computed from pairs of stable consecutive beats; and 2) the 3-beat indices of ventricular repolarization variation, computed in triplets of stable consecutive beats ( ${\mathrm{I}_{\rm{V3}}}$ ). Results: These indices showed a significant association with sudden cardiac death (SCD) outcome in the study population. In addition, risk assessment based on the combination of the proposed indices improved stratification performance compared to their individual potential. Conclusion: Patients with enhanced ventricular repolarization variation computed in terms of the proposed indices were successfully associated to a higher SCD incidence in our study population, evidencing their prognostic value. Significance: using a simple ambulatory ECG recording, it is possible to stratify AF patients at risk of SCD, which may help cardiologists in adopting most effective therapeutic strategies, with a positive impact in both the patient and healthcare systems.

Objective : We proposed and evaluated a method for correcting possible phase shifts provoked by the presence of ventricular premature contractions (VPCs) for a better assessment of T-wave alternans (TWA). Methods: First, we synthesized ECG signals with artificial TWA in the presence of different noise sources. Then, we assessed the prognostic value for sudden cardiac death (SCD) of the long-term average of TWA amplitude (the index of average alternans, $IAA$ ) in ambulatory ECG signals from congestive heart failure (CHF) and evaluated whether it is sensitive to the presence of VPCs. Results: The inclusion of the phase correction after VPC in the processing always improved estimation accuracy of the $IAA$ under different noisy conditions and regardless of the number of the VPCs included in the sequence. It also presented a positive impact on the prognostic value of $IAA$ with increased hazard ratios (from 17% to 29%, depending of the scenario) in comparison to the noninclusion of this step. Conclusion: The proposed methodology for $IAA$ estimation, which corrects for the possible phase reversal on TWA after the presence of VPCs, represents a robust TWA estimation approach with a significant impact on the prognostic value of $IAA$ for SCD stratification in CHF patients. Significance: An accurate TWA estimation has a potential direct clinical impact on noninvasive SCD stratification, allowing better identification of patients at higher risk and helping clinicians in adopting the most appropriate therapeutic strategy.

Repolarization Dynamics and Mortality in Heart Failure. Introduction: Repolarization dynamics, reflecting adaptation of QT to changing heart rate, is considered a marker of unfavorable prognosis in patients with heart diseases. We aimed to evaluate the prognostic value of QT/RR slope in predicting total mortality (TM) and sudden death (SD) in patients with congestive heart failure (CHF). Methods and Results: In 651 sinus rhythm patients with CHF in NYHA class II-III enrolled in the MUSIC study, 24-hour Holter monitoring was performed at enrollment to assess slope of the QTa/RR (QT apex) and QTe/RR (QTend) during the entire 24-hour Holter recording and separately during day and night periods. Patients were followed for a median of 44 months, with the primary endpoint defined as TM and the secondary as SD. Analysis of repolarization dynamics was feasible in 542 patients (407M), mean age 63 years, 83% in NYHA class II, 49% with ischemic cardiomyopathy, with mean LVEF 37%. Mean value of QTa/RR slope was 0.172 and QTe/RR was 0.193. During the 44-month follow-up there were 119 deaths including 47 SD. Nonsurvivors were characterized by steeper QT/RR slopes. Increased QT/RR slopes during the daytime (>0.20 for QTa and >0.22 for QTe) were independently associated with increased TM in multivariate analysis after adjustment for clinical covariates with respective hazard ratios 1.57 and 1.58, P = 0.002. None of the dynamic repolarization parameters was associated with increased risk of SD in the entire population. Conclusions: Abnormal repolarization dynamics reflected as increased daytime QT/RR slopes is an independent risk stratifier of all-cause mortality in patients with chronic heart failure © 2008 Wiley Periodicals, Inc.

Abnormal heart rate turbulence (HRT) has been documented as a strong predictor of total mortality and sudden death in postinfarction patients, but data in patients with congestive heart failure (CHF) are limited.The aim of this study was to evaluate the prognostic significance of HRT for predicting mortality in CHF patients in New York Heart Association (NYHA) class II-III.In 651 CHF patients with sinus rhythm enrolled into the MUSIC (Muerte Subita en Insuficiencia Cardiaca) study, the standard HRT parameters turbulence onset (TO) and slope (TS), as well as HRT categories, were assessed for predicting total mortality and sudden death.HRT was analyzable in 607 patients, mean age 63 years (434 male), 50% of ischemic etiology. During a median follow up of 44 months, 129 patients died, 52 from sudden death. Abnormal TS and HRT category 2 (HRT2) were independently associated with increased all-cause mortality (HR: 2.10, CI: 1.41 to 3.12, P.001 and HR: 2.52, CI: 1.56 to 4.05, P.001; respectively), sudden death (HR: 2.25, CI: 1.13 to 4.46, P = .021 for HRT2), and death due to heart failure progression (HR: 4.11, CI: 1.84 to 9.19, P.001 for HRT2) after adjustment for clinical covariates in multivariate analysis. The prognostic value of TS for predicting total mortality was similar in various groups dichotomized by age, gender, NYHA class, left ventricular ejection fraction, and CHF etiology. TS was found to be predictive for total mortality only in patients with QRS120 ms.HRT is a potent risk predictor for both heart failure and arrhythmic death in patients with class II and III CHF.

BACKGROUND: Even if atrial fibrillatory rate (AFR) has been related to clinical outcome in patients with atrial fibrillation (AF), its relation with ventricular response has not been deeply studied. The aim of this study was to investigate the relation between AFR and RR series variability in patients with AF. METHODS: Twenty‐minute electrocardiograms in orthogonal leads were processed to extract AFR, using spatiotemporal QRST cancellation and time frequency analysis, and RR series in 127 patients (age 69 ± 11 years) with congestive heart failure (NYHA II–III) enrolled in the MUSIC study (MUerte Subita en Insufficiencia Cardiaca). Heart rate variability and irregularity were assessed by time domain parameters and entropy‐based indices, respectively and their correlation with AFR investigated. RESULTS: Variability measures seem not to be related to AFR, while irregularity measures do. A significant correlation between AFR and variability parameters of heart rate variability during AF was found only in patients not treated with antiarrhythmics drugs (correlation = 0.56 P

Smoking has been related to coronary heart disease, and, in men, to sudden death. The results of a case-control study designed to assess the relationship between smoking and all causes of sudden and premature death are reported.A questionnaire on the previous history and causes of death of all people buried in the Municipal Cemetery of Valencia (1986-1987) was administered to the relatives of the deceased. Among 4718 deaths, 284 victims of sudden death were identified, and 495 people who had not died suddenly were randomly sampled as controls.The proportion of smokers among the women studied was extremely low in contrast to 58.9% of men in the sudden death study group and 59.2% of men in the non-sudden death study group who smoked. Smokers died on average 10 years younger than non-smokers in the sudden-death group (63.3 +/- 12.3 and 73.3 +/- 11.0 years respectively; P0.001), and 8 years earlier in the non-sudden death group (68.5 +/- 13.3 and 76.8 +/- 13.2 years, respectively; P0.001). A logistic regression model showed that smokers had an adjusted relative risk of 0.81 for sudden death compared with non-smokers (95% confidence interval [CI]: 0.45-1.46). Smokers 65 years of age or under had a 2.7 times greater risk (95% CI: 1.49-5.04) of premature death than non-smokers. Similar results were found in patients from the coronary- and cardiac-death subgroups.Smoking is an independent risk factor for premature death but not for sudden death.

among patients with heart failure (HF), body mass index (BMI) has been inversely associated with mortality, giving rise to the so-called obesity paradox. The aim of this study was to examine the relationship between BMI and two modes of cardiac death: pump failure death and sudden death.nine hundred seventy-nine patients with mild to moderate chronic symptomatic HF from the MUSIC (MUerte Subita en Insuficiencia Cardiaca) Study, a prospective, multicenter, and longitudinal study designed to assess risk predictors of cardiac mortality, were followed up during a median of 44 months. Independent predictors of death were identified by a multivariable Cox proportional hazards model.higher BMI emerged as an independent predictor of all-cause mortality (hazard ratio [HR] = 0.94, 95% confidence interval [CI] = 0.91-0.97, P = .0003) and pump failure death (HR = 0.93, 95% CI = 0.88-0.98, P = .004). Sudden death accounted for 45% of deaths in obese patients, 53% in overweight patients, and 37% in lean patients. No significant relationship between BMI and sudden death was observed (HR = 0.97, 95% CI = 0.92-1.02, P = .28). The only independent predictors of sudden death were prior history of myocardial infarction (HR = 1.89, 95% CI = 1.23-2.90, P = .004), hypertension (HR = 1.66, 95% CI = 1.05-2.63, P = .03), left ventricular ejection fraction (HR = 0.88, 95% CI = 0.79-0.96, P = .006), and N-terminal pro-B-type natriuretic peptide (HR = 1.01, 95% CI = 1.00-1.02, P = .048).the obesity paradox in HF affects all-cause mortality and pump failure death but not sudden death. The risk of dying suddenly was similar across BMI categories in this cohort of ambulatory patients with HF.

The prognosis of chronic heart failure (CHF) is extremely variable, although generally poor. The purpose of this study was to develop prognostic models for CHF patients. A cohort of 992 consecutive ambulatory CHF patients was prospectively followed for a median of 44 months. Multivariable Cox models were developed to predict all-cause mortality (n = 267), cardiac mortality (primary end-point, n = 213), pump-failure death (n = 123), and sudden death (n = 90). The four final models included several combinations of the same 10 independent predictors: prior atherosclerotic vascular event, left atrial size > 26 mm/m(2), ejection fraction 1.000 ng/L, and troponin-positive. On the basis of Cox models, the MUSIC Risk scores were calculated. A cardiac mortality score > 20 points identified a high-risk subgroup with a four-fold cardiac mortality risk. A simple score with a limited number of non-invasive variables successfully predicted cardiac mortality in a real-life cohort of CHF patients. The use of this model in clinical practice identifies a subgroup of high-risk patients that should be closely managed.

The population of patients with heart failure (HF) and mild to moderate left ventricular (LV) dysfunction is growing, and mortality remains high. There is a need for better risk stratification of patients who might benefit from primary prevention of mortality. This study aimed to evaluate the prognostic value of Holter-based parameters for predicting mortality in patients with HF with LV ejection fraction (EF) >35%. The study involved 294 patients (199 men, mean age 66 years) with HF of ischemic and nonischemic causes, New York Heart Association classes II to III, and LVEF >35%. Surface electrocardiogram and 24-hour Holter monitoring were performed at enrollment to assess traditional electrocardiographic variables, as well as heart rate variability, heart rate turbulence, and repolarization dynamics (QT/RR). Total mortality and sudden death were the primary and secondary end points. During a median 44-month follow-up, there were 43 deaths (15%). None of the traditional electrocardiographic risk parameters significantly predicted mortality. A standard deviation of all normal-to-normal RR intervals ≤86 ms, turbulence slope ≤2.5 ms/RR, and QT end/RR >0.21 at daytime were found to be independent risk predictors of mortality in multivariate analyses. The predictive score based on these 3 variables showed that patients with ≥2 abnormal risk markers were at risk of death (30% 3-year mortality rate) and sudden death (12%), similar to death rates observed in patients with LVEF ≤35%. In conclusion, increased risk of mortality and sudden death could be predicted in patients with HF with LVEF >35% by evaluating the combination of standard deviation of all normal-to-normal RR intervals, turbulence slope, and QT/RR, parameters reflecting autonomic control of the heart, baroreflex sensitivity, and repolarization dynamics.

Congestive heart failure (CHF) is an increasingly widespread, costly and deadly disease, frequently named as epidemics of the 21 century. Despite advancement in modern treatment, mortality rate in CHF patients remains high. Therefore, risk stratification in patients with CHF remains one of the major challenges of contemporary cardiology. Electrocardiographic parameters based on ambulatory Holter monitoring have been documented to be independent risk predictors of total mortality and progression of heart failure. Recent years brought an increased interest in evaluation of dynamic Holter-derived ECG markers reflecting changes in heart rate and ventricular repolarization behavior. It is widely accepted that structural changes reflecting myocardial substrate are better identified by means of imaging techniques, Holter monitoring on the other hand provides complementary information on myocardial vulnerability and autonomic nervous system. Therefore, combining the electrocardiographic stratification with assessment of myocardial substrate may provide the complex insight into interplay between factors contributing to death. The present article reviews the literature data on the prognostic role of various Holter-based ECG parameters, with special emphasis to dynamic ECG risk markers--heart rate variability, heart rate turbulence, repolarization dynamics and variability--in predicting mortality, as well as different modes of death in patients with CHF.

Objective The association between low blood pressure (BP) levels and increased mortality has been established in several studies of heart failure (HF). Although many drugs administered to these patients decrease BP, the relationship between changes in BP and survival has not been investigated. Nor have previous analyses distinguished among different forms of death. We investigated the influence of baseline BP and changes in BP during a 1-year period on the survival of patients with HF, distinguishing among sudden cardiac death, nonsudden cardiac death, and noncardiac death. We also identified the possible relationship with the baseline values of and changes in other clinical and treatment variables, including pharmacologic treatments. Method and Results A total of 1062 patients with chronic HF included in the Spanish National Registry of Sudden Death (mean age of 64.5 ± 11.8 years, 72% were men, and 21% were in New York Heart Association class III with a mean left ventricular ejection fraction of 36.7% ± 14.2%) were prospectively investigated for a mean of 1.9 ± 0.6 years. A multivariable Cox proportional hazards model adjusting for clinical and therapeutic variables showed an independent association between low baseline systolic blood pressure (SBP) and nonsudden cardiac death (hazard ratio [HR] 0.96, 95% confidence interval [CI] 0.93–0.98), but changes in SBP during the following year did not influence survival, regardless of the baseline SBP level ( P = .55). Contrariwise, baseline diastolic BP was not associated with mortality, but an increase in diastolic BP during the following year showed a borderline independent significant association with lower nonsudden cardiac death (HR 0.90, 95% CI 0.82–1.00). Treatment with angiotensin-converting enzyme inhibitors or beta-blockers at baseline was also associated with lower nonsudden cardiac mortality, as was an increase in left ventricular ejection fraction during the following year (HR 0.69, 95% CI 0.51–0.93; P = .015). Conclusion Among patients with stable HF, low SBP is associated with a greater risk of nonsudden cardiac death. The change in SBP during a 1-year period has no prognostic value. Because the beneficial effects of drugs associated with increased survival (in this study, angiotensin-converting enzyme inhibitors and beta-blockers) thus seem to be independent of their effects on BP, changes in BP should probably not influence the decision to use such drugs or continue their administration.

Patients with severe angina pectoris, refractory to medical treatment, in which conventional revascularization (PTCA or bypass surgery) is not possible because they present advanced coronary artery disease with a poor distal bed, account for an important clinical problem due to an increasing incidence, combined with poor quality of life, an elevated risk of severe complications, repeated hospital admissions and high mortality rate. Laser transmyocardial revascularization provides a new therapeutic alternative for these patients. Although up to now there are only a few published series, with a small number of patients, the results obtained in the two ongoing multicentric studies in Europe and the United States (including more than 500 patients at present) are quite promising. It is a simple surgical procedure, but its associated mortality is not to be dismissed (in the beginning 12% and currently 5%), because patients are in an advanced evolutionary stage. In Spain this procedure has been available since April 1996 and the results have been encouraging. In our small series we have noted a significant symptomatic improvement and better quality of life.

A randomized trial was conducted to assess the efficacy of amiodarone versus metoprolol or no antiarrhythmic treatment to suppress asymptomatic ectopic activity and improve survival in patients who have had myocardial infarction with a left ventricular ejection fraction of 20 to 45% andor = 3 ventricular premature complexes per hour (pairs or runs). Patients (n = 368) were randomly assigned to receive amiodarone 200 mg/day (n = 115) 10 to 60 days after the acute episode, and metoprolol 100 to 200 mg/day (n = 130) or no antiarrhythmic therapy (n = 123). After a median follow-up of 2.8 years, mortality in the amiodarone-treated patients (3.5 +/- 2% SEM) did not differ significantly from that of untreated control subjects (7.7 +/- 2.5%, p = 0.19), but was lower than that in the metoprolol group (15.4 +/- 3.5%, p = 0.006). Patients treated with metoprolol had twice the mortality seen in control subjects, even though the differences were not statistically significant. Holter studies performed at 1, 6 and 12 months showed that both amiodarone and metoprolol were equally effective in reducing heart rate, whereas only amiodarone significantly reduced ectopic activity (p0.0001). Thus, long-term treatment with amiodarone was clearly safe in patients with an ejection fraction of 20 to 45%, was effective in suppressing arrhythmias, and was associated with a lower mortality than metoprolol; corroboration is required in a larger trial.

On the basis of our reported experience with colchicine for recurrent pericarditis, we administered colchicine to two patients with large pericardial effusions complicating idiopathic pericarditis. The first was a 26‐year‐old male who showed clinical deterioration following emergency pericardiocentesis and aspirin (3 g/day) for 10 days; the second was a 2‐year‐old girl who was unsuccessfully treated with aspirin (100 mg/kg/day) for 2 weeks, followed by corti‐costeroids for 7 months. Administration of colchicine (1 mg/ day) instead of aspirin in the first case, and with a rapid tapering‐off of the corticosteroids in the second case, led to complete regression of the pericardial effusion on echocardiography within 1 week and 1 month, respectively. Colchicine was discontinued after 1 month in the first patient and was continued for 6 months in the child. Neither has had a recurrence at 24 and 6 months of follow‐up, respectively. No side effects of colchicine were observed. We conclude that colchicine may be effective in the treatment of large pericardial effusion when therapy with nonsteroidal anti‐inflammatory drugs and/or corticosteroids fails.

Patients with advanced interatrial conduction block with retrograde activation to the left atrium present a high incidence of supraventricular tachyarrhythmias. We report the value of preventive antiarrhythmic treatment in these patients.